Although advances in free flap surgery have allowed the reconstruction of a wide range of complex scalp defects, simpler local options continue to play a role. We describe how bipedicled or 'bucket handle' scalp flap with skin grafting of the donor site can be used to resurface large scalp defects of up to 15 cm x 20 cm. This retrospective case series of 11 patients describes flap outcomes, post-operative complications, pathology and patient-related outcomes collected via a questionnaire. Defect sizes ranged from 56 cm
Dupuytren's surgery 114 Synovial cyst treatment 119 Arthrodesis in the hand 121 Arthroplasty in the hand 124 Extensor tendon repair 127 Flexor tendon repair 131Tendon transfers 134 Soft tissue reconstruction 137 Trigger finger surgery 141 Trigger thumb surgery 142 Viva questions 143Patients are ready for Dupuytren's surgery if they have a flexion deformity that is interfering with their activities of daily living. Using the 'table-top test' (i.e. inability to get the hand flat on the table) or specific degrees of flexion deformity (e.g. =30° at the proximal interphalangeal [PIP] joint) as an indication for surgery is unhelpful as they may over-or underestimate the need for surgery.
We describe a series of six cases exploring the limits of reliability of the dorsal ulnar artery fasciocutaneous flap as described by Becker and Gilbert (1988a; b). Although the territory supplied by the dorsal ulnar artery is 10 cm to 20 cm long by 5 cm to 9 cm wide, Becker and Gilbert suggested that flaps should be confined to smaller dimensions. We have found that larger flaps (15 to 20 cm long and 5 to 8 cm wide) are feasible, extending the use of the flap to the radial side of the wrist and hand. However, problems were encountered with venous drainage and these larger flaps should be used with caution.
This work was performed to generate the data needed to set epidemiological cut-off values for minimal inhibitory concentrations (MICs) of 10 antimicrobial agents against Vibrio parahaemolyticus determined using standardised broth microdilution protocols. Eight laboratories performed broth microdilution tests with incubation at 35°C for 16 to 20 h, and 7 also performed tests on the same isolates with incubation at 28°C for 24 to 28 h. Data were analysed by the ECOFFinder and normalised resistance interpretation algorithms. The cut-off values calculated for ceftazidime, florfenicol and trimethoprim/sulfamethoxazole, 1, 1 and 0.25/4.75 µg ml -1 , respectively, were the same when calculated from data obtained at both temperatures. The cut-off values calculated from data obtained at 35°C and from data obtained at 28°C were 0.25 and 0.5 µg ml -1 for enrofloxacin, 2 and 4 µg ml -1 for gentamicin, 0.5 and 1 µg ml -1 for oxolinic acid and 2 and 1 µg ml -1 for oxytetracycline, respectively. The influence of incubation temperature on MIC values was investigated by comparing MICs obtained at 35 and 28°C for a specific antimicrobial agent with a particular isolate by an individual laboratory. Results showed that 56% of 1473 of these paired MIC values were identical, while 38% differed from one another by not more than 1 dilution step. The data generated in this work will be submitted to the Clinical and Laboratory Standards Institute for consideration in their setting of internationally agreed epidemiological cut-off values for V. parahaemolyticus that are essential for interpreting antimicrobial susceptibility testing data of this species.
Aims Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. Methods A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed. Results There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312). Conclusion The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential. Cite this article: Bone Joint J 2020;102-B(2):162–169.
ABSTRACT Introduction We report on the outcomes of using a custom-built osseointegrated (OI) intraosseous transcutaneous amputation prosthesis (ITAP) as a bone anchor for prosthetic reconstruction of a series of amputated fingers. The aim of ITAP was to reduce the risk of failure due to infection by creating a biological seal at the skin-implant interface. Methods and Results A total of 14 patients who suffered from amputations of their digits at a variety of different levels were recruited. Eleven patients (20 implants) underwent treatment with an implant based on the ITAP principle. With the exception of one patient (1 implant), all implants were removed by 9 years after insertion. Patients requested removal because of recurrent infections, exposure of the flange structure (unique to ITAP), loosening of the implant, and inability to secure a prosthesis to the implant. Conclusions The ITAP principle does not work when used as part of the design of an OI bone anchor for prosthetic reconstruction after finger amputation. Clinical Relevance Statement This study suggests that there are major problems with the principles underlying the design of the ITAP implant when used in humans. Future studies of OI implants using the principles of ITAP may be at risk of similar problems.
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